Blog: Managing the Care of Health

The Haphazardly Informed We

18 May 2017

This blog is adapted from two passages of my new book Managing the Myths of Health Care.

The patient is the “single most underused person in health care”. This means you and me. We are not casual players when it comes to our health, no matter how passive we may be in front of our doctors.

Much of the time, we are not even in front of them, or even patients. We have to take primary responsibility for the care of much of our own health, including the prevention of diseases. Moreover, we are often the “first responders.” We feel something coming on and get ourselves to a professional, or else just deal with some problem ourselves. (Have you put on a bandage lately?)  And not just for ourselves. We can be the first responders for our children, sometimes even for our elderly parents. So we better be well informed.

This blog is adapted from two passages of my new book Managing the Myths of Health Care.

The patient is the “single most underused person in health care”. This means you and me. We are not casual players when it comes to our health, no matter how passive we may be in front of our doctors.

Much of the time, we are not even in front of them, or even patients. We have to take primary responsibility for the care of much of our own health, including the prevention of diseases. Moreover, we are often the “first responders.” We feel something coming on and get ourselves to a professional, or else just deal with some problem ourselves. (Have you put on a bandage lately?)  And not just for ourselves. We can be the first responders for our children, sometimes even for our elderly parents. So we better be well informed.

How well are we informed? There is a vast array of health care information out there: how much of what we need to know actually gets to us? Is 10% a gross exaggeration?

I go into the supermarket and see eggs, Omega 3 and Organic. Which is better? I always mean to check on the Internet when I get home, but I always forget. What’s the use? The answer will probably change soon anyway. But it’s not the reliability of the information that bothers me so much as the rendering of it for my personal use.

So how do I get informed for my very survival?  Haphazardly. Had I not had the radio on a particular day last year, I would not have heard that I no longer need to force eight glasses of water down my throat every day. But this year, had I listened to my medical friends and not gone to see a naturopath, I would not have found out that, for a particular condition I have, I had better drink all that water after all. Is this any way to get informed about my health—a radio program here, TV news there, a consultation, an article sent by a friend, and most systematically of all, ads telling me what pain killer to swallow?

And I’m advantaged: well educated, with time to read. Plus I have physician friends I can call about these things. And now, thanks to the Internet, I can find all kinds of information to misinterpret. Mostly, however, I am overwhelmed by the information available, and underwhelmed by what of it I get. I need HELP!!!

Health Navigator to the rescue

General practitioners, even the most responsive ones, are busy people. They have to diagnose, treat or refer, and advise—usually with a waiting room full of anxious people. We, the people out there, need something more.

So let me suggest the role of health navigator. Don't confuse this with nurse practitioner, who comes from the perspective of medicine, as a supplement to physicians. It should be noted that there's a lot more to health care than what physicians mostly do, including the promotion of health (especially diet), the prevention of many illnesses, and the treatment of those that medicine has yet to address (such as IBS and many auto-immune conditions).  Other services, such as acupuncture, naturopathy, and homeopathy, do treat some of these conditions—in my experience, at times remarkably well—yet get marginalized by a medical establishment that can be doubly blind.

A health navigator, professionally trained, would provide information and advice to you and I, the persons beneath the patients—in our communities, beneath the epidemiologists’ populations. The health navigator would:

  • Get to know us, as individuals and in our community, beginning with an extensive first interview about all aspects of our health (as homeopaths do), and continuing to maintain that understanding.
  • Remain abreast of health care information in general, as well as of the reliable sites that provide it, and of the services that are available in our community.
  • Provide us with whatever of that information each of us needs, alongside advice to help maintain our health.
  • In the event of illness, guide us through the intricacies of diagnosis, treatment, and especially recovery.

The diagram below shows the five key aspects of health care—maintaining health, detecting illness, diagnosing disease, treating disease, and recovering health—around two concentric circles. The outer one is labelled the Professional Ring while the inner one, closer to ourselves, is labelled the Personal Sphere. The health navigator would work all around he circle—as shown in the diagram, in the Professional Ring but close to the Personal Sphere.

Seeing the Parts around the Whole

 

Must we leave the fate of our health to the haphazardness of the information marketplace as well as to the limitations of medical practice? Or shall we find our proper place in the care of our own health?

© Henry Mintzberg 2017 with passages from Managing the Myths of Health Care.

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ANNOUNCING my new book

19 April 2017

Managing the Myths of Health Care

BERRETT-KOHLER  AMAZON UK  AMAZON

From the back cover:

“Health care is not failing but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs, and herein lies the failure.”

Managing the Myths of Health Care

BERRETT-KOHLER  AMAZON UK  AMAZON

From the back cover:

“Health care is not failing but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs, and herein lies the failure.”

In this sure-to-be-controversial book, leading management thinker Henry Mintzberg turns his attention to reframing the management and organization of health care.

The problem is not management per se but a form of remote-control management detached from the operations yet determined to control them. It reorganizes relentlessly, measures like mad, promotes a heroic form of leadership, favors competition where the need is for cooperation, and pretends that the calling of health care should be managed like a business.

“Management in health care should be about dedicated and continuous care more than interventionist and episodic cures.”

The professional form of organizing is the source of health care’s great strength as well as its debilitating weakness. In its administration, as in its operations, it categorizes whatever it can to apply standardized practices whose results can be measured. When the categories fit, this works wonderfully well. The physician diagnoses appendicitis and operates; some administrator ticks the appropriate box and pays. But what happens when the fit fails—when patients fall outside the categories or across several categories or need to be treated as people beneath the categories, or when the managers and professionals pass each other like ships in the night?

To cope with all this, Mintzberg says that we need to reorganize our heads instead of our institutions. He discusses how we can think differently about systems and strategies, sectors and scale, measurement and management, leadership and organization, competition and collaboration.

“Market control of health care is crass, state control is crude, professional control is closed. We need all three—in their place.”

The overall message of Mintzberg’s masterful analysis is that care, cure, control, and community have to work together, within health-care institutions and across them, to deliver quantity, quality, and equality simultaneously.

Some other excerpts:

In management no less than medicine, scalpels usually work better than axes.

Narrowness pervades health care, from professionals on the ground who can’t see past their specialities, to managers in the offices who can’t see past their institutions, analysts in governments and insurance companies who can’t see past their numbers, and economists in the air who can’t see past their dogma.

Reorganizing is the expected disjointed intervention for a health care “system” built on disjointed interventions.

While the ill act as a concerted force for spending more locally, the healthy act as a general lobby for spending less nationally. This makes the field of health care sick.

There are no management problems in health care, separate from medical problems, nursing problems, or prevention problems. There are only health care problems.

Because economics begins before medicine ends, the technocrats of health care have too often trumped the professionals.

In the name of competition, health care suffers from individualism: every patient, provider, and institution for themselves.

The field of health care may be appropriately supplied by businesses, but in the delivery of its most basic services, it is not a business at all, nor should it be run like one. At its best, it is a calling.

I can think of no field that is more global in its professional practices yet more parochial in its administrative ones than health care.

Certainly we have to measure what we can; we just cannot allow ourselves to be mesmerized by measurement—as we so often are.

Physicians who like to belittle hierarchies of authority are often slaves to their own hierarchies of status.

Who can possibly be against evidence in medicine? Me, for one, when it is used as a club to beat up on experience.

The essential problem in health care may lie in forcing detached administrative solutions on to practices that require informed and nuanced judgments.

It can be taken as almost an axiom of professional work that dysfunctional practices cannot be fixed by tighter administration. The problems have to be addressed within the work itself.

Strategy making in the field of health care tends to be about venturing more than visioning, and personal and collective learning more than institutional planning.

When we promote leadership, we demote everyone else. How about plain old management?

Instead of people pointing the finger at each other, they should be pointing their fingers together at the procedures and structures that set them apart.

Health care doesn’t need more measuring and reorganizing so much as better cultures of collaboration that open up the pathways of communication.

A systems perspective requires a focus on the person in the community, beyond a patient in a population.

There’s a massive amount of health care information out there, some of which I need to know. How much of that part am I actually getting? Is 10 percent a gross exaggeration? And how do I get even that? Haphazardly!

To find the systems perspective in health care, look first in the mirror: we are as close as we are going to get. That is because you and I are significantly responsible for promoting our own health, preventing our potential illnesses, and even treating many of our own diseases.

The invisible hand that is supposed to serve everyone by serving ourselves turns out to be a visible underhand in much of health care when it serves some users at the expense of others.

See full Table of Contents

© Henry Mintzberg 2017

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Do you run for cure? How about running for cause.

27 July 2016

You probably know people who have had some sort of cancer. You also know many more who will be getting these diseases—you just don’t know who they are. So when you “Run for Cancer”, the money likely goes for those people who have the disease, to find a cure, rather than to the investigation of cause, so that many more people needn’t get the disease in the first place. We certainly need to celebrate concern for the ill, but shouldn’t we show equivalent concern for the healthy, so that they don’t get ill? Is not an ounce of prevention worth a pound of cure?

You probably know people who have had some sort of cancer. You also know many more who will be getting these diseases—you just don’t know who they are. So when you “Run for Cancer”, the money likely goes for those people who have the disease, to find a cure, rather than to the investigation of cause, so that many more people needn’t get the disease in the first place. We certainly need to celebrate concern for the ill, but shouldn’t we show equivalent concern for the healthy, so that they don’t get ill? Is not an ounce of prevention worth a pound of cure?

Part of the problem lies with medicine itself. It is mostly about treating diseases, and since physicians do so much of the research, that’s where the bulk of the funding goes. I asked a surgeon active in breast cancer research about the proportion of funding that went to finding cause. She estimated it to be 1%. (Some physicians even refer to as “prevention” stopping Stage 1 breast cancer from advancing to Stage 2. That’s like claiming that the cause of Stage 2 cancer Is Stage 1 cancer.) True there are diseases such as Alzheimer’s that do better, but how many others are like breast cancer?

And let’s not get started on pharmaceuticals, except to note that there is no money to be made from people who are well, or at least usually a lot less money from one-shot vaccines to keep them well. So developing medications gets most of the big bucks, and siphons off a great deal of the creative talent that could be looking for causes. All around, our health care needs to be better focused on the care of health.

John Robbins has written a wonderful allegory about a cliff that people kept falling over. There thus developed a highly sophisticated effort to treat the injured, involving physicians, ambulances, and hospitals with the latest technological wizardly. Efforts were even undertaken to develop drugs to cure the injuries of the fallen. When some people suggested building a fence atop the cliff, they were ignored, or else dismissed: what did they know about health care?1

Dr Jonas Salk didn’t buy any of this. He never cured any child of polio. Instead he ensured that no child ever had to be cured. His laboratory developed a vaccine that eradicated the disease. We need more money and talent dedicated to stopping diseases, including studying the toxic effects of what we inhale, ingest, and absorb. And by the way, Dr Salk refused to patent his vaccine, with the comment that “Who owns my polio vaccine? The people. Could you patent the sun?” He could have made a great deal of money by ensuring at the outset that only the children of rich parents could get the vaccine. Instead children all over the world became protected rather quickly.

Researching cause can be quite different from researching cure. It is often more like detective work, where samples of one can be perfectly appropriate. After all, find the cause in someone and you may be on your way to finding the cause in everyone.

A 2003 poll by Hospital Doctor named Dr John Snow the greatest physician ever. Partly he earned that with a sample of 2. When an outbreak of cholera exploded in London’s Soho District in 1854, believing that the disease was water-born, even though the physicians who mattered were convinced it was air-born, he plotted the locations of the recent victims on a map. They clustered around one well, all except two, who lived miles away. Like a good detective, Dr Snow visited the home of one of them. A relative told him that she liked the water of that well and had someone fetch it for her. Her niece also liked that water, he was told, and she died too. And where did she live? There was sample Number 2. Finally Dr Snow’s colleagues listened to him. (Sewage seeping into the well—i.e., toxin—was later found to be the cause of the outbreak.). The handle of the well was removed—that was the cure! (for this well at least)—and the epidemic ended.

Some years ago, I heard about an astonishingly high incidence of certain cancers among children in Alexandria. So for this TWOG I went on the internet and found one related article, in the Journal of the Egypt Public Health Association, 2002, under the title “Patterns in the incidence of pediatric cancer in Alexandria, Egypt, from 1972 to 2001.” The article concluded that “The trends in some cancer types suggest the need of a closer examination of the underlying factors and environmental contaminants leading to the disease in children.” Yes indeed, and what a perfect place to research cause. But who is to do that: where is the constituency for cause?2 In other words, where are the Dr Snow’s when we need them now?

If you have lost a cherished member of your family to a dreaded disease, I can well understand your wish to help find a cure for it.  But cannot this emotion also be directed into helping avoid the suffering of others? So please, the next time you run for a disease, or fund a research chair, or just donate a few pennies for health care, consider cause. Invest in health.

© Henry Mintzberg 2016. HM is the Founding Director of the International Masters for Health Leadership (imhl.org) and author of the forthcoming Managing the Myths of Health Care (Berrett-Koehler, 2017). Follow this TWOG on Twitter @mintzberg141, or receive the blogs directly in your inbox by subscribing hereTo help disseminate these blogs, we now also have a Facebook page and a LinkedIn.


2 I found no follow-up study, nor any comments on that one.